Provider Demographics
NPI:1033107032
Name:BRANDYWINE HEALTH SERVICES OF MS INC
Entity Type:Organization
Organization Name:BRANDYWINE HEALTH SERVICES OF MS INC
Other - Org Name:CHOCTAW COUNTY NURSING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RAY
Authorized Official - Middle Name:
Authorized Official - Last Name:SHOEMAKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-285-6234
Mailing Address - Street 1:PO BOX 1039
Mailing Address - Street 2:
Mailing Address - City:ACKERMAN
Mailing Address - State:MS
Mailing Address - Zip Code:39735
Mailing Address - Country:US
Mailing Address - Phone:662-285-3257
Mailing Address - Fax:662-285-2516
Practice Address - Street 1:311 E CHERRY ST
Practice Address - Street 2:
Practice Address - City:ACKERMAN
Practice Address - State:MS
Practice Address - Zip Code:39735-9795
Practice Address - Country:US
Practice Address - Phone:662-285-3257
Practice Address - Fax:662-285-2516
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-12
Last Update Date:2008-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS242314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0230167Medicaid
MS0230167Medicaid